Physical Activity and Cognitive Decline Among Older Adults

Key Points Question Is physical activity associated with cognitive decline? Findings This systematic review and meta-analysis including a total of 104 studies with 341 471 participants found a weak association between baseline physical activity and follow-up global cognition that was evident also in episodic memory and verbal fluency domains. Neither study quality, follow-up length, baseline age, nor adjustment for preceding level of cognition moderated the association, and there was no clear dose-response association between the amount of physical activity and global cognition. Meaning These findings suggest that physical activity might postpone cognitive decline at a population health level but only to a very small extent.


eMethods
This meta-analysis examines the relationship between PA and cognition.A separate pre-registered meta-analysis examined the relationship between PA and the incidence of all-cause dementia, Alzheimer's disease, and vascular dementia.The study plan originally encompassed both meta-analyses and was submitted to PROSPERO 2.12.2017 (prior to the first search of the review 11.12.2017).The registration was accepted 8.1.2018.The plan of the search has been described in PROSPERO (registration number CRD42018083236) and addressed the relationship of PA with both cognition and dementia.The original searches and the first update from 2020 have been described in the already published the systematic review and meta-analysis addressing PA and dementia [1].
After the first reduced update search, two additional extensive updates have been one: one targeting dementia in 2021 and one targeting cognition in 2022.The search terms for PA and study type in the extensive update targeting cognition carried out in 2022 are similar as in the already published update targeting dementia from 2021 [1].The search terms for cognition are the same as in the original searches in 2017 to 2018.These additional extensive updates are better targeted than the first original search that yield greatly irrelevant studies.The searches of the latest update were done October 29, 20212 in CINAHL, PubMed, Web of Science, scopus, November 2, 2022 in PsycInfo and SPORTDiscus.Two examples of the original searches have been previously published [1].Below are the 2022 update searches targeting PA and cognition from all databases.

Specifications to the inclusion and exclusion criteria at the title and abstract screening phase in cases of disagreements:
The studies are included if • All the other criteria are fulfilled but cognition is the independent variable and PA the dependent variable.These we include because in the full text, researchers may consider the association vice versa also.• It is not clear whether the article describes cross-sectional or longitudinal results from a longitudinal study (this has not been specified and for example, the cohort's name encompasses the word longitudinal or something similar).• It is unclear at this point whether cognition is measured or self-reported.
• The study adjusts for vascular risk factors and on the basis of the abstract, it is not absolutely clear, what these vascular risk factors are (PA might be one of them).
The studies are excluded if • Outcome variable is clearly something else than cognition.
• It has been specified in the abstract that the report is cross-sectional even if "longitudinal" or similar phrase is in the name of the study cohort.

Specifications to the inclusion and exclusion criteria at the full-text review phase in cases of disagreements:
The studies are included if • We have to have either a measure of whole cognition based on which it is possible to deduce if the participant has cognitive impairment or not at baseline or we have a valid measure of a single cognitive domain and it has been measured both at baseline and at follow-up and the analyses take into account the baseline measure of cognition The studies are excluded if • Only figure of the estimate of the association of PA and cognition has been presented but no numerical results and the authors do not provide these numbers after email inquiry.• The outcome is a subjective rating of one's own memory.
• A method to screen dementia at baseline has been a measure of dementia difficulty not a valid measure of cognition (like for example Clinical Dementia Rating).• The study examines the association of only tai chi, pilates, yoga or other similar types of low-intensity PA while ignoring all other PA.• Studies measuring only indoor PA with PIR sensors.
• The study uses linear mixed model to examine the association of PA with cognition at all measurement points including the baseline • The study examines the association of PA intercept (from a growth model or latent intercept), not baseline PA.

Data extraction:
The studies were deemed to adjust for preceding level of cognition if they had a valid measure of preceding cognition as covariate in their analysis model.An exception to this was linear mixed models with the level of cognition as the outcome in which the study needed to have baseline cognition x time interaction term in the model.
The estimates with the best quality score and the most extensive set of adjustments were extracted.If two sets of results were presented, we chose the unimputed ones with cognitive impairment at baseline excluded, dementia developed during the first years of follow-up excluded, or more sensitive cut-off for cognitive impairment.For example, if the main analysis included participants with existing cognitive impairment but a subgroup analysis with a smaller sample size excluded those with existing cognitive impairment, the estimate of association from the subgroup analysis was included in the meta-analysis.
One study presented the estimates of the association between PA with episodic memory and processing speed in different age groups 2 .We only used the estimates for middle-age to avoid baseline levels being lowered due to dementia.Some of the studies had reported only unstandardized beta coefficients without standard deviations of the outcome variable or it was unclear for us whether the estimate was standardized or not.The authors were contacted to obtain the standard deviation of the outcome variable in these cases: many replied and cordially provided us with the information while some did not.

Quality review:
One criterion of the quality assessment tool presented in our previous meta-analysis of PA 1 and dementia was different for this meta-analysis of PA and cognition: the length of follow-up had to be at least 10 years for all studies except for those in which the follow-up was in midlife (defined as mean or median age less than 55 years and maximum age less than 65 years or mean age plus one standard deviation (SD) less than 60 years).For studies in which follow-up was in midlife, good quality could be reached with at least five years of follow-up.
If a quality criterion could not be assessed from the study article, at maximum three cited publications were reviewed.

More details about the transformations used in the meta-analyses 1.3.1 Binary analyses
In the analysis of dichotomous outcomes, odds ratios and hazard ratios were transformed into risk ratios.Odds ratios were transformed with the following formula when the outcome was rare (< 10 %) 3 .

Where: p0= outcome incidence in the whole study population OR=Odds ratio
If the outcome was common (> 10 %), we used square root transformation of odds ratios 4 :

Where: RR=Risk ratio OR=Odds ratio
Hazard ratios were transformed using the following formula dementia for the reference group) 5 .

Where: r=The incidence rate of cognitive impairment or decline RR=Risk ratio HR=Hazard ratio
If the number of persons with and without event at follow-up were given, risk ratio was calculated with the following formula:

Where: N=Sample size RR=Risk ratio
If confidence interval for a binary outcome was not given, but a p-value for it was presented, we calculated the confidence interval from the p-value in the following manner 6 : 95 %  =  (ln( )+1.96*  (7) Where: SE= standard error z = z -score CI = Confidence interval Most studies reported hazard, odds or risk ratio for the risk of cognitive impairment or decline, but a few studies reported risks for different cognitive trajectories.In almost all studies examining risks for different cognitive trajectories, only one of these trajectories was clearly declining and the other ones were relatively stable 7 -10 .We pooled the risk for rapid decline in comparison with the most stable cognition group into the meta-analysis.Any trajectories between the most and least stable were excluded from this meta-analysis.In one study, two trajectories were declining and one was stable 11 .Since, the other declining trajectory had the same starting point as the stable group, we included the risk for this declining trajectory into the meta-analysis.

Analyses of rate of change in cognition
In many papers, the outcome was the rate of change in cognition (for example, the interaction term of PA x time from linear mixed models).The time unit used in all but one study was years.One study presented their results per five years 12 and these were divided by five to yield the rate of change per year.To pool the studies of rate of change, we multiplied the standardized regression coefficients for rate of change with the length of the follow-up in years to yield us the change in cognition 13 .

Estimation of a standard deviation for a continuous outcome variable
If standard deviations were reported only for subgroups but not for the whole group we used the following formula to derive the within-sub-group standard deviation 14 :

SD= Standard deviation
When we did not have information on standard deviation of cognition at baseline, but standard deviation for intercept of cognition from the model of cognition change was given, we used the standard deviation of the intercept 15 .
When standard deviation was not given in the article, we used interquartile range to estimate the standard deviation 14 :  = ( − ) 1.349 (12)   Where: SD=Standard deviation For animal fluency (the number of animal names produced in 60 seconds), we used the interquartile range from other published data on noninstitutionalized population of older adults as a reference 16 .
When a ln transformation of a variable was used because of a skewed distribution, we calculated a standard deviation for the ln transformed variable in the following manner 14 : Where:

SD(lnX)=Standard deviation of a ln transformed PA variable SD X =Standard deviation of PA variable (not ln transformed) M X =Mean of PA variable
For the studies in which we were not able to standardize the outcome, we contacted authors to provide us with the standard deviation of the outcome.

Standardized regression coefficient from comparison of mean values between two exposure groups
When regression coefficients or post-follow-up mean scores with standard deviations for a binary PA variable were presented we calculated standardized regression coefficient with the following formula 14 : Where: If p-value was presented as "< 0.05", we transformed it into confidence intervals using an approximation of p-value = 0.049 in the calculations and similarly, if p-value was denoted as "> 0.1" or ">0.05", we approximated it to p-value ≈0.55.
If a p-value was not given, we used the following formula to estimate standard error for β 14 and calculated confidence interval with equations 10 and 11: Where: When regression coefficients for change or pre-and post-follow-up mean scores with standard deviations for a binary PA variable were presented we calculated standardized regression coefficient with the following formula 14 : Confidence interval for the results was calculated from the p-value with formulas 4, 15, 16 and 17.If p-value was not given but a F-value from repeated measures of analysis of variance (ANOVA) was given, we calculated the p-value from the F-value.
If a p-value for the unstandardized regression coefficient was not given, we used the following formula to estimate standard error for standardized regression coefficient 14 and calculated confidence interval with equations 16 and 17: (ℎ 1 − ℎ 2 ) = √ We used linear trend test to estimate standardized regression coefficient when the outcome was presented for a categorized exploratory variable with more than two exposure groups.A simple linear regression line was drawn with categories of exposure as x-axis (contrast values) and the outcome values as the y-axis 14 .We used MET (metabolic equivalent of task) -minutes, absolute energy expenditure, or PA scores as contrast values if readily available or easily calculated and values 0, 1, 2, 3, … k in cases where MET-minutes, absolute energy expenditure, or PA scores was not easily available (k is the number of categories).β with standard error was obtained in the following manner 14 : One study reported follow-up scores with standard deviations and p-value from a generalized linear regression model but not the regression coefficient.For this study, we calculated the standardized regression coefficient from follow-up scores using formulas 23 and 8.We calculated confidence intervals for this standardized regression coefficient using the p-value from the generalized linear regression model with formulas 4, 15, 16 and 17.

Dose-response plots
We approximated the midpoint of each PA category to metabolic equivalent of energy expenditure (MET) -minutes 1,18 .
Next, we plotted these MET-minutes for each category against the relevant magnitude of association of the corresponding category in a scatterplot of MET-minutes and magnitudes of association for cognition.The scatter dot sizes were drawn to reflect the sample size of the corresponding PA category.After this, we fitted linear, polynomial, and quadratic lines to these scatter plots and chose the visually best one to be presented in the graphs.The studies that used continuous measures of PA were excluded from this analysis.
The midpoint of each PA category was regarded as the PA exposure for each group 18 .Some studies reported PA in MET-minutes or MET-hours.These studies did not need approximation.Some studies reported the amount of PA and some description of the intensity.For these studies, the intensity was estimated in the following manner: walking = 3.5 MET, sport = 4 MET, moderate PA = 4.5 MET, vigorous PA = 8 MET, light PA = 2.25 MET, light and moderate PA combined = 3.25 MET (midpoint of 4 (sport) and 2.5 (light PA)), moderate-to vigorous PA = 5 MET.For studies in which PA was assessed with frequency but not with duration, the duration was estimated to be 45 minutes for moderateto vigorous PA and 60 minutes for other PA.Studies in which PA was expressed in kcal, MET-minutes were calculated using the following formula 1 : Where: kcal=Kilocalorie kg=Body weight in kilograms When mean body weights were not given in the study, a continental average body weights were used 19 .As in our previous meta-analysis 1 , we imputed the PA exposure for studies in which MET-minutes was impossible to estimate from other similar studies.The cut-off for meeting the PA recommendation 20 of moderate-to vigorous PA was estimated to be 500 MET-minutes per week.If a mean could not be calculated for the highest PA category, the mean for the highest PA category group was set near the cut-off.

Other approximations used in the meta-analysis
Most studies reported mean or median baseline age but for studies that did not, the midpoint of the range given was used.b See "Performance quality" in the quality assessment tool (Supplementary material).One star=1, Half a star=2, No star=3 and if the two reviewers disagreed, then we took the average of the two reviews.c Other vascular risk factor = a cardiovascular disease or information on smoking, BMI, cholesterol levels, diet, blood pressure, diabetes or blood glucose

1. 3 . 5
Standard error of standardized regression coefficient n 1 = Sample size of the group 1 n 2 = Sample size of the group 2 SD(Y) = full sample standard deviation of outcome variable Y SD(X) = Standard deviation of independent variable X SE (b)= Standard error of unstandardized regression coefficient.M 1 = Mean for the group 1 M 2 = Mean for the group 2 SD 1 = Standard deviation of the outcome for the group 1 SD 2 = Standard deviation of the outcome for the group 2 Standardized regression coefficient for change from comparison of pre-and post-follow-up test scores between two exposure groups regression coefficient n 1 = Sample size of the group 1 n 2 = Sample size of the group 2 Change 1 = Mean change score for the group 1 Change 2 = Mean change score for the group 2 SD(Y) = full sample standard deviation of outcome variable Y at baseline [13, 17] © 2023 Iso-Markku P et al.JAMA Network Open.b = unstandardized regression coefficient.

2 1. 3 . 6
) Where: SE(β) = Standard error of standardized regression coefficient n 1 = Sample size of the group 1 n 2 = Sample size of the group 2 SD(Y) = full sample standard deviation of outcome variable Y at baseline SD(X) = Standard deviation of independent variable X SE (b)= Standard error of unstandardized regression coefficient.Change 1 = Change for the group 1 Change 2 = Change for the group 2 SD 1 = Standard deviation of the outcome at baseline for the group 1 SD 2 = Standard deviation of the outcome at baseline for the group Standardized regression coefficient from more than two exposure groups regression coefficient SD(contrast) = Standard deviation of the selected contrast values SD(Y) = Standard deviation of the outcome variable b c = Regression coefficient of the linear regression line from the linear trend test SE(β) = Standard error of the standardized regression coefficient SE(b c ) = Standard error of the regression coefficient from the linear trend test.

eTable 3 .
Tests used to assess continuous global cognition, verbal fluency and naming, working memory, verbal ability and visuo-spatial ability Abbreviations: 3MS = Modified Mini Mental States Examination, CANTAB = Cambridge Neuropsychological Test Automated Battery, MMSE = Mini Mental State Examination, TICS = Telephone Interview for Cognitive Status, WAIS = Wechsler Adult Intelligence Scale, WAIS-R= Wechsler Adult Intelligence Scale Revised words, each of which had another five words next to it.For each 20 words, the participant was asked to select which of the five words next to it had a similar meaning) -Markku P et al.JAMA Network Open.

eTable 4 .
Abbreviations: CANTAB = Cambridge Neuropsychological Test Automated Battery, CERAD = the Consortium to Establish a Registry for Alzheimer's Disease, CVLT = California Verbal Learning Test, HVLT= Hopkins Verbal Learning Test, RVLT = Rey Verbal Learning Test, TICS = Telephone Interview for Cognitive Status, VADAS =the Vascular Dementia Assessment Scale -cognitive subscale, WAIS = Wechsler Adult Intelligence Scale, WAIS-R= Wechsler Adult Intelligence Scale Revised

3 ) 1 )Outcome 1 ) 3 )Baseline 1 ) 2 ) 4 )Comparability 1 )Outcome 1 ) 3 )
Demonstration that outcome of interest was not present at start of study a) Yes.In a study population whose average age > 55 years, valid measure of cognition is used and demented individuals and individuals with mild cognitive impairment at baseline according to baseline cognition screening have been excluded or population is in midlife (mean age or median < 55 years and maximum age 65 years or +1 SD < 60 years) (one star) Comparability of cohorts on the basis of the design or analysis controlled for confounders a) The study controls for the following four factors: age, sex (or all cohort members represent the same sex), some vascular risk factor † and education or a measure of general cognitive ability at baseline (education criterion is not needed if all cohort members have the same education level).In addition, the results have been adjusted with baseline cognition in study population whose average age > 55 years (one star)b) The study controls only for three of the factors presented above (age, sex, some vascular risk factor and education or a measure of general intelligence) or/and in study populations whose mean age > 55 years the results have not been adjusted with baseline cognition or the sociodemographic and health behaviors controlled for are not specified further (half a star) c) Cohorts are not comparable on the basis of covariates controlled for (no star) Assessment of outcome a) A validated measure of dementia (one star) b) Record linkage (half a star) c) Self report or other d) No description a) Yes (one star) b) NoIndicate the median duration of follow-up and a brief rationale for the assessment above: 10 years in dementia studies.Adequacy of follow-up of cohorts a) Complete follow up-all subject accounted for (one star) b) Subjects lost to follow up unlikely to introduce bias-number lost less than or equal to 20%* (when follow-up less than 10 years) or 30%* (when follow-up at least 10 years) of those alive or description of those lost suggested no different from those followed.(one star) c) Follow up rate less than 80%* (when follow-up less than 10 years) or less than 70%* (when follow-up longer than 10 years) and no description of those lost.d) No statement * Follow-up rates are calculated taking into account only the cohort members who have been alive at the time of the follow-up † Vascular risk factor signifies a cardiovascular disease or information on smoking, body mass index, cholesterol levels, diet, blood pressure, diabetes or blood glucose.Thresholds for converting the Newcastle-Ottawa scales to AHRQ standards (good, moderate, and poor): Good quality: Selection: 2,5 -3 stars, Comparability: 1 star, Outcome: 2,5 -3 stars Moderate quality: Selection: 2-3 stars, Comparability: 0,5 -1 star, Outcome: 2-3 stars, Poor quality: studies not reaching Moderate/Good quality 1.6 A quality assessment tool for the quality assessment of case-control studies addressing the association of physical activity and dementia or cognition (originally published in British Journal of Sports Medicine: Iso-Markku et al.Br J Sports Med 2022;56:701-709.doi: 10.1136/bjsports-2021-104981) Note: A study can be given a maximum of one star for each numbered item within the Selection, Comparability and Outcome categories.Selection of controls: a) Community controls (half a star) Definition of controls: a) No history of disease (endpoint) (half a star) b) No description of source 3) Demonstration that outcome of interest was not present at start of study a) Yes.In a study population whose average age > 55 years, valid measure of cognition is used and demented individuals and individuals with mild cognitive impairment at baseline according to baseline cognition screening have been excluded or population is in midlife (mean age or median < 55 years and maximum age 65 years or +1 SD < 60 years) (one star) Performance quality (adapted from (Br J Sports Med 2017;51:1410-18)) a) Good: PA assessed with a structured questionnaire of the duration, frequency and intensity of PA or the intensity of PA assessed with a structured question.Or PA assessed with an objective measure of PA (eg.accelerometer).Additionally same method is used for cases and controls and non-response rate is the same for cases and controls.(one star) b) Moderate: Participation only in some types of sports assessed but other activities not considered or assessment of intensity lacks.Frequency or duration are assessed.(half a star) c) Low: A "yes" or "no" question used.Frequency and duration not assessed.Or physical activity index on versatility of sports and somewhat physical household chores but not assessing intensity, frequency or duration.(no star) Comparability of cohorts on the basis of the design or analysis controlled for confounders a) The study controls for the following four factors: age, sex (or all cohort members represent same sex), some vascular risk factor † and education or a measure of general cognitive ability at baseline.In addition, the results have been adjusted with baseline cognition in study population whose average age > 55 years (one star) b) The study controls only for three of the factors presented above (age, sex, some vascular risk factor and education or a measure of general intelligence) or in study populations whose mean age > 55 years the results have not been adjusted with baseline cognition (half a star) c) Cohorts are not comparable on the basis of covariates controlled for (no star) Assessment of outcome a) A validated measure of dementia (if many cognitive tests used, most validated) (one star) b) Record linkage (half a star) © 2023 Iso-Markku P et al.JAMA Network Open.c) Self report or other d) No description 2) Was follow-up long enough for outcomes to occur a) Yes (one star) b) No Indicate the median duration of follow-up and a brief rationale for the assessment above: 10 years in dementia studies.Is the case definition adequate?: a) Yes, with a valid measure of dementia (half a star) b) No, does not fulfil the criteria defined above 4) Representativeness of the cases: a) Consecutive or obviously representative series of cases (half a star) b) Potential for selection biases or not stated † Vascular risk factor signifies a cardiovascular disease or information on smoking, body mass index, cholesterol levels, diet, blood pressure, diabetes or blood glucose.Thresholds for converting the Newcastle-Ottawa scales to AHRQ standards (good, moderate, and poor): Good quality: Baseline: 2,5 -3 stars, Comparability: 1 star, Outcome: 2,5 -3 stars Moderate quality: Baseline: 2-3 stars, Comparability: 0,5 -1 star, Outcome: 2-3 stars, Poor quality: studies not reaching Moderate/Good quality 2. Supplementary analyses eFigure 1. Quality of the studies © 2023 Iso-Markku P et al.JAMA Network Open.

eTable 5 .
Physical activity and cognition, binary outcomes, supplementary analyses a a Statistically significant results are bolded.
Review Article (Exclude -Document Types) and 2022 or 2021 or 2020 or 2019 or 2018 or 2017 (Publication Years) and Article (Document Types) and Pediatrics or Orthopedics or Cardiovascular System Cardiology or Research Experimental Medicine or Nutrition Dietetics or Science Technology Other Topics or Mathematics or Endocrinology Metabolism or Biochemistry Molecular Biology or Surgery or Education Educational Research (Exclude -Research Areas) and Tropical Medicine or Social Work or Parasitology or Operations Research Management Science or Music or Meteorology Atmospheric Sciences or Mechanics or International Relations or Government Law or Geology or Forestry or Fisheries or Film Radio Television or Entomology or Construction Building Technology or Chemistry or Biotechnology Applied Microbiology or Biodiversity Conservation or Veterinary Sciences or Religion or Plant Sciences or Microbiology or Philosophy or Medical Ethics or Imaging Science Photographic Technology or History or Hematology or Criminology Penology or Anthropology or Zoology or Virology or Transportation or Instruments Instrumentation or Automation Control Systems or Women Apos S Studies or Urban Studies or Substance Abuse or Rheumatology or Public Administration or Linguistics or Geography or Arts Humanities Other Topics or Women S Studies or Robotics or Food Science Technology or Cell Biology or Biophysics or Audiology Speech Language Pathology or Anesthesiology or Dentistry Oral Surgery Medicine or Critical Care Medicine or Agriculture or Ophthalmology or Otorhinolaryngology or Information Science c Filters: Library Science or Urology Nephrology or Ethnic Studies or Dermatology or Emergency Medicine or Obstetrics Gynecology or Reproductive Biology or Mathematical Computational Biology or Gastroenterology Hepatology or Toxicology or Telecommunications or Engineering or Business Economics or Respiratory System or Infectious Diseases or Oncology or Pharmacology Pharmacy or Communication (Exclude -Research Areas) and SPORTS CONCUSSION VIRTUAL CONFERENCE or 27TH ANNUAL MEETING OF THE SOCIETY FOR THE STUDY OF INGESTIVE BEHAVIOR SSIB (Exclude -Conferences/Meeting Titles) and English (Languages) Field of search: Abstract d Filters: English, Publication source: Journal, Published: 2017 -2022 (search 29.10.2021),Field of search: Abstract Search: ( ( ABS ( "physical activity" ) ) OR ( ABS ( "aerobic exercise" ) ) OR ( ABS ( sport* ) ) OR ( ABS ( walking ) ) OR ( ABS ( "physical training" ) ) ) AND ( ( ABS ( cognition ) )OR ( ABS ( cognitive ) ) OR ( ABS ( "executive function" ) ) OR ( ABS ( tele ) ) OR ( ABS ( tics ) ) OR ( ABS ( mmse ) ) OR ( ABS ( 3-ms ) ) OR ( ABS ( memory ) ) OR ( ABS ( "processing speed" ) ) OR ( ABS ( "verbal fluency" ) ) OR ( ABS ( "semantic fluency" ) ) OR ( ABS ( reasoning ) ) OR ( ABS ( "delayed recall" ) ) ) AND ( ( ABS ( prospective ) ) OR ( ABS ( longitudinal ) ) OR ( ABS ( follow-up ) ) OR ( ABS ( observational ) ) OR ( ABS ( cohort ) ) ) AND ( LIMIT-TO ( DOCTYPE , "ar" ) ) AND ( EXCLUDE ( SUBJAREA , "ENGI" ) OR EXCLUDE ( SUBJAREA , "PHAR" ) OR EXCLUDE ( SUBJAREA , "COMP" ) OR EXCLUDE ( SUBJAREA , "IMMU" ) OR EXCLUDE ( SUBJAREA , "BUSI" ) OR EXCLUDE ( SUBJAREA , "DENT" ) OR EXCLUDE ( SUBJAREA , "EART" ) OR EXCLUDE ( SUBJAREA , "ECON" ) OR EXCLUDE ( SUBJAREA , "VETE" ) OR EXCLUDE ( SUBJAREA , "CHEM" ) OR EXCLUDE ( SUBJAREA , "ENER" ) OR EXCLUDE ( SUBJAREA , "DECI" ) OR EXCLUDE ( SUBJAREA , "PHYS" ) OR EXCLUDE ( SUBJAREA , "CENG" ) OR EXCLUDE ( SUBJAREA , "MATE" ) OR EXCLUDE ( SUBJAREA , "MATH" ) ) AND ( LIMIT-TO ( PUBYEAR , 2022 ) OR LIMIT-TO ( PUBYEAR , 2021 ) OR LIMIT-TO ( PUBYEAR , 2020 ) OR LIMIT-TO ( PUBYEAR , 2019 ) OR LIMIT-TO ( PUBYEAR , 2018 ) OR LIMIT-TO ( PUBYEAR ,

Definitions of cognitive impairment and decline Publication Definition of cognitive impairment
2) cognitive impairment not dementia; or(3)no cognitive impairment.The risk for both dementia and cognitive impairment not dementia was extracted for this meta-analysis.Woodard 2012Significant cognitive decline was defined as exhibiting a one SD reduction or greater on at least one of the three principal outcome indices (Mattis Dementia Rating Scale -2, RAVLT Sum of Trials 1-5, RAVLT Delayed Recall).Standardized residual change scores were computed to adjust for baseline performance, practice effects, and regression to the mean.Nonamnestic impairment.Digit Symbol Substitution, Digit span (total span), and Category Fluency tests.Raw scores on each of these tests administered at baseline in the entire cohort were converted to standardized z scores, which were averaged to form a composite score.Nonamnestic impairment was defined as performance at or below 1 standard deviation from the mean composite score in this cohort.2.Cerebrovascular disease defined as presence of any 1 of Hachinski ischemic score of 4 or higher, presence of hemiparesis on clinical evaluation, or history of strokes verified by medical records and imaging studies.Verghese 2006 Amnestic mild cognitive impairment (aMCI).Subjects were diagnosed with aMCI if they met the following criteria: 1) does not meet criteria for dementia; 2) objective memory impairment defined as three or more errors on the five-item Blessed test memory phrase.This cutscore corresponds to performance at or below 1.5 SDs from the mean (1.1 ± 1.4) in this age restricted sample.Roesch 2021 German J MCI: (1) cognitive concern expressed by a physician, informant, participant, or study coordinator; (2) impairment in one or more cognitive domains (memory, attention/executive function, language, or visuospatial skills); (3) essentially normal functional activities; and (4) absence of dementia.Participants with MCI had a CDR score of 0 or 0.5; however, the final diagnosis of MCI was based on all available data.Cognitive domains were assessed with the following neuropsychological test battery: memory (delayed recall trials from Rey Auditory Verbal Learning Test, Wechsler Memory Scale Revised Logical point drop in z-score in the Chinese MMSE.The z-score was derived from the raw scores based of participants who had a global CDR of zero at the baseline.Global score is the average of the z-scores of TICS, immediate and delayed recalls of the East Boston Memory Test, delayed recall of TICS 10-word list, test of category fluency and digit backwards test.Three trajectories were constructed and only one trajectory declined (other ones were high stable and medium stable).
2023 Iso-Markku P et al.JAMA Network Open.eTable 2. and constructional praxis, immediate memory and delayed recall, attention and speed of mental processing; and the Stroop and Trail Making tests as measures of executive.Patient cognitive status was classified into the following groups: (1) dementia; © 2023 Iso-Markku P et al.JAMA Network Open.(Wang 2006 Neuropsychological evaluation: the cognitive status was assessed using the Chinese version of MMSE with the cutpoint previously defined as 17 (illiteracy), 20 (6 years of education), and 24 (6 years of education) for cognitive impairment (below cut-off).mental status examination, and findings from the neurologic examination when available.We combined dementia and CIND partly to improve our statistical power.© 2023 Iso-Markku P et al.JAMA Network Open.Abbreviations: 3MS = Modified Mini Mental State Examination, CAMCOG = Cambridge Cognitive Examination, CDR = Clinical Dementia Rating, DSST = Digit Symbol Substitution Test, MMSE = Mini Mental State Examination, MOCA = Montreal Cognitive Assessment, MSQ= Mental Status Questionnaire, RAVLT = Rey Auditory Verbal Learning Test, SD=Standard deviation, SPMSQ = Short Portable Mental Status Questionnaire, WAIS-R = Wechsler Adult Intelligence Scale Revised Krell-© 2023 Iso-Markku P et al.JAMA Network Open.

delayed recall and recognition of 10-word list from CERAD Digits backwards, a shortened version of CANTAB Spatial Working Memory Tests and Stroop Word-Color Interference Stroop part 1 (word reading) and part 2 (color naming) East Boston Memory Test immediate and delayed recall Animal fluency and a letter cancellation test (speed and accuracy) Trails Making Test Part A TICS 10-word list recall The symbol Digit Modalities Test, Stroop interference, animal fluency and Trails Making Tests B -A Digit cancellation Delayed recall of the Rey-Osterrieth Complex figure test Digit span backwards, Trails Making Test A and B, Letter Digit Substitution Test, Verbal fluency Maze subtask of VADAS Logical Memory Test The difference in time to complete the Color Trails test Form 1 and Form 2 and the sum of the Odd-Man-Out subtests 2 and 4 the Grooved Pegboard task in the nondominant hand, the Color Trails test Form 1, and the Visual-Motor Integration test Paired Associates Behavioral dyscontrol scale CANTAB Reaction time IU Story Recall Visual Elevator test, Brixton Spatial Anticipation test and Verbal Fluency test Wecshler Memory Scale revised Logical Memory and Visual Reproduction Backward digit span, category fluency, number series, backward counting, stop-go switch task Stroop interference, Letter Digit Substitution Task, category fluency Action recall, sentence recall, cued recall, word list learning from Betula study [21] Trails Making Tests B and Digit Symbol Substitution Test Other immediate and delayed recall tests of with varying number of words Factor score for EF from MMSE, List Learning, Digit Span, Stroop, Clock Drawing, Figure copying, Letter fluency Factor score for memory from MMSE, List Learning, Digit Span, Stroop, Clock Drawing, Figure copying, Letter fluency 1.5 A quality assessment tool for the quality assessment of cohort studies addressing the association of physical activity and dementia or cognition (originally published in British Journal of Sports Medicine: Iso-Markku et al. Br J Sports Med 2022;56:701-709. doi: 10.1136/bjsports-2021-104981)
Note: A study can be given a maximum of one star for each numbered item within the Selection, Comparability and Outcome categories.Participation only in some types of sports assessed but other activities not considered or assessment of intensity lacks.Frequency or duration are assessed.(halfa star) c) Low: A "yes" or "no" question used.Frequency and duration not assessed.Or physical activity index on versatility of sports and somewhat physical household chores but not assessing intensity, frequency or duration.Or not described how exercise or physical activity was measured.(no star) d Drop-out rate has been extracted only by a single reviewer See "Performance quality" in the quality assessment tool (Supplementary material).One star=1, Half a star=2, No star=3 and if the two reviewers disagreed, then we took the average of the two reviews.c Other vascular risk factor = a cardiovascular disease or information on smoking, BMI, cholesterol levels, diet, blood pressure, diabetes or blood glucose. b